Provider Demographics
NPI:1982154589
Name:DETORE, RACHAEL THERESA
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:THERESA
Last Name:DETORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WYCKOFF CT
Mailing Address - Street 2:
Mailing Address - City:ASBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08802-1091
Mailing Address - Country:US
Mailing Address - Phone:908-537-9794
Mailing Address - Fax:
Practice Address - Street 1:342 HAMBURG TPKE STE 202
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2166
Practice Address - Country:US
Practice Address - Phone:973-870-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00878300363A00000X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program